Pediatric emergency medicine trisk 2908 2908

postinfectious glomerulonephritis, MPGN, and lupus nephritis. Additional
studies to be considered include HIV, hepatitis B and C serologies in highrisk patients, and serum antinuclear antibodies, especially in children with
symptoms of SLE or aged 10 years or more.
Management. Given that there are two major processes leading to edema
in nephrotic syndrome, arterial underfilling due to low oncotic pressure and
primary renal sodium retention, management of fluid excess requires
careful attention to the underlying causes. Diuretic therapy would be
effective in reducing edema and indicated if the primary process is renal
sodium retention. However, if hypoalbuminemia leads to decreased plasma
volume via movement of fluid from the vascular space to the interstitium,
diuretic therapy may aggravate arterial underfilling. As it may be difficult to
determine intravascular volume in patients with nephrotic syndrome,
clinical characteristics that may predict intravascular volume status include
GFR and serum albumin level. Patients with decreased vascular volumes
and severe hypoalbuminemia may require albumin infusions in conjunction
with diuretics in order to maintain arterial filling pressures. Children who
present with severe edema should be admitted and may be treated with
furosemide and albumin (e.g., 25% albumin) to achieve diuresis. Albumin
(0.5 to 1 g/kg) infused over 4 hours followed by one to two doses of
furosemide (0.5 to 1 mg/kg/dose) should result in fluid mobilization.
Providing albumin will bolster the intravascular oncotic pressure and
safeguard against volume depletion during fluid mobilization.
Once the patent is stabilized, a plan for sodium and fluid restriction
should be made. Optimally, children are restricted to approximately 2 to 3
mEq/kg/day of sodium or up to a maximum of 2,000 mg/day in older
children and adolescents. Water restriction should be initiated given the
release and action of ADH resulting in dilutional hyponatremia. Admission
for close volume management should be strongly considered if evidence of
hypovolemia is apparent at presentation or uncontrolled fluid loss is
anticipated (i.e., gastroenteritis) given the risk for thromboembolic
complications and prerenal kidney injury.

Children with nephrotic syndrome who are hemodynamically stable
should be started on daily prednisone at 2 mg/kg or 60 mg/m2 after
consultation with a nephrologist. If they do not require hospital admission
for close fluid balance monitoring, they should be followed closely as an